Contraception after having a baby

When you’ve just had a baby, the last thing you’re likely to think about is your next one. This is why postpartum contraception is so important. We break it down for you here.

You can resume sexual intercourse when you and your partner feel ready and comfortable. There really is no minimum time period and it has been reported that up to 50% of women will resume sexual activity within six weeks after delivery. However, it is down to the individual couple involved; some may feel more comfortable waiting several months before they are ready.

In all mothers there is a theoretical chance of ovulation, and therefore a possibility of conception and pregnancy, from day 21 after delivery. Therefore, if it has been more than 21 days since your delivery and you are sexually active, you will need to use contraception.

Leaving adequate time between babies

Having a baby is a major life change that impacts your time, sleep and finances. As such, another surprise within a short time can leave you underprepared and less able to cope with your new arrival. It is also medically important to have adequate spacing of births. One reason is that you need to give time to your body to recover after the birth, especially if you delivered by caesarean section. Furthermore, there is evidence that suggests that intervals of less than 12 months between childbirth and subsequent conception may be associated with increased risk of preterm delivery, fetal growth restriction and small for gestational age babies. However, if you do get pregnant earlier, there is no cause for worry; ask for advice from your doctor, midwife or nurse.

Choosing which contraception works best for you

There are several options for contraception and your choice will be based on yours and your partner’s preferences, any medical conditions you have, how long it has been since you gave birth and whether you are breast-feeding.

You can discuss your options with hospital staff following delivery, at your home visits with the midwife, at your 6-week check with the GP or indeed at any other time with either your GP or family planning clinic.

The mini pill (progesterone only pill)

The progesterone only pill (POP) can be started at any time, including immediately after birth. POPs are taken continuously and without a pill-free interval, i.e. there is no induced monthly period, but most women will get some spotting, particularly in the first year. The POP is 99% effective with correct use but it should be taken at roughly the same time every day. This is something to think about when you have a new baby as with so much going on, it can easily be forgotten. Newer pills containing desogestrel have a safe window of 12 hours in case you forget to take it at your set time and can be a good idea for new mothers. There are very few contra-indications to POPs but certain other medications may make it less effective.

The combined oral contraceptive pill (COCP)

It is called the combined pill as it contains both ethinylestradiol (estrogen) and a form of synthetic progesterone. It is also available in a skin patch or a vaginal ring form. Typically, the pill is taken for 21 days with a 7-day interval during which time there is a bleed. It is 99% effective if taken correctly.
Usually this type of contraception is not given immediately postpartum due to the risk of blood clots in pregnancy which can be increased by the pill. These risks have usually normalised by 6 weeks postpartum, at which time it is safer to take the pill. The COCP can be used if you are breast-feeding and it is more than 6 weeks after delivery.

The COCP is not a good option for women who are smokers, overweight or have a history of high blood pressure or migraines; this is due to ongoing increased risks of blood clots.

Intrauterine contraception

Intrauterine contraception has the highest effectiveness of all the contraceptive options. It includes the intrauterine system (Mirena coil) and the copper coil. The Mirena coil contains a small amount of progesterone, lasts for 5 years and most women find that they have reduced or no bleeding. The copper coil has no hormones, so women will continue to have their periods, which can be heavier as a result of the coil. The copper coil can last for either 5 or 10 years depending on the exact type.
Both options can be inserted in the first 48 hours after delivery or at the time of caesarean section, though not all hospitals will offer this. There is a chance that the device can fall out, so it is recommended that you also use barrier contraception until your GP can check it is still in place at your 6-week postnatal check.

If a coil is not inserted within 48 hours, you will usually have to wait 28 days after delivery to have one fitted. This is because as the womb is returning to its smaller pre-pregnancy size, the chance of the coil puncturing (perforating) the wall of the womb is higher, especially in breast-feeding mothers.

The implant

This is another effective contraceptive (more than 99% effectiveness) and contains progesterone. It is inserted under the skin in the upper arm and lasts for three years. It can be inserted immediately after delivery or at any time thereafter. It is safe to use with breastfeeding and there are very few contraindications. Most women experience infrequent bleeding or no bleeding, but irregular bleeding can occur.

The injection

It is as effective and works in a similar way to the implant and again can be started immediately following delivery but needs to be given every 13 weeks. It does not interfere with breastfeeding.

If you are breastfeeding it is recommended to have the injection 6 weeks after delivery to reduce the risk of developing blood clots. Bleeding patterns are similar to the implant. Some reported side effects include acne and weight gain. It can take up to a year for your fertility to return to normal once you stop having the injection.

Barrier contraception

This includes, male condoms (98% effective with correct use), female condoms (95% effective with correct use), diaphragms or caps (92 to 96% effective if used correctly). These are easy to obtain and easy to use methods of contraception but they are slightly less effective than the other methods discussed. They can be started at any time following delivery but you should wait six weeks before using a diaphragm or a cap. You may need a different size diaphragm/cap to the one you were using pre-baby.

Fertility awareness

Tracking changes such as body temperature and cervical mucus, or trying to calculate when ovulation will occur are unreliable in the postpartum period due to different hormone levels.

Will contraception affect my breast milk?

Available evidence indicates that progestogen-only-based contraception has no adverse effect on lactation, infant growth or development.

There is currently limited evidence regarding the effects of Combined Hormonal Contraceptives (COCP, vaginal ring, contraceptive patch) on breastfeeding. However, there is no evidence that the use of CHC can have adverse effects on either breastfeeding performance (duration of breastfeeding, exclusivity and timing of initiation of supplemental feeding) or on infant outcomes (growth, health and development).

Lactational amenorrhoea

The use of breastfeeding as contraception is known as the lactational amenorrhoea method (LAM). Suckling causes high levels of prolactin which shuts down the menstrual cycle and as a consequence suppresses ovulation. However, as suckling reduces ovulation returns.

LAM can be an effective method of contraception up to 98% if the below criteria are met:

• It is less than 6 months after delivery
• You are fully and exclusively breastfeeding (short intervals: at least 4-hourly during the day and 6-hourly during the night)
• Amenorrhoeic (your periods have not returned yet)

Expressing milk might reduce the efficacy of LAM. The effectiveness of LAM will reduce as your child gets older and the frequency of breastfeeding decreases, night time feeds stop or menstruation returns.

Sexually transmitted infections

Most methods of contraception don’t protect you from sexually transmitted infections. Only condoms when used correctly and consistently can help reduce the risk of getting a sexually transmitted infection.

Who can arrange contraception for me/where should I go for advice?

It is good practice to plan contraception in advance. You can discuss this with your midwife, GP, doctor, health visitor or sexual health clinic nurse. You can do this any time, but especially before being discharged from hospital or during the postnatal check with your GP.

Can I use emergency contraception soon after giving birth?

Yes. You should consider emergency contraception if it is 21 days since the birth and you either had unprotected intercourse or think your contraception might have failed. If intercourse occurred within 20 days of giving birth, emergency contraception is not required.

Emergency contraception includes the copper coil (Cu-IUD) or oral hormonal tablets.

Cu-IUD is safe to use from 28 days after childbirth.

With regards to the hormonal tablets, they are safe to use from 21 days after childbirth. The tablets are:

• Oral levonorgestrel 1.5mg
• Oral Ulipristal acetate 30mg (known as ellaOne)

The pill you are given will depend on the time following intercourse as well as any medications you take. Women who breastfeed should be advised not to breastfeed and to express and discard milk for a week after they have taken an ulipristal acetate tablet. If you choose to take levonorgestrel you can continue to breastfeed.

Main Points

• Sexual activity and fertility can resume shortly after childbirth, and therefore there is a risk of pregnancy unless contraception is initiated 3 weeks after delivery or you are exclusively breastfeeding.
• Short inter‐pregnancy intervals (of less than 1 year) can increase the risk of obstetric and neonatal complications.
• The antenatal and postpartum periods present a unique opportunity to discuss contraceptive options, many of which can be safely initiated immediately after childbirth.
• Contraceptive options include the progesterone only pill, the combined oral contraceptive pill, intrauterine contraception (coils), the implant, the injection, barrier contraception.
• Evidence indicates that progestogen-only-based contraception has no adverse effect on lactation, infant growth or development. The evidence of the effects of Combined Hormonal Contraceptives on breastfeeding, however, is not as clear.
• Breastfeeding as contraception (LAM) can be an effective method of contraception but only if certain criteria are met.
• It is safe to use emergency contraception after childbirth (although it will not be needed if it is 20 days or less since the birth). However, if taking an ulipristal acetate tablet when breastfeeding, you should express and discard breast milk for a week after taking this form of emergency contraception.

Reference:

i. Your guide to contraceptive choices – after you’ve had your baby Helping you choose the method of contraception that’s best for you, leaflet produced by FPA ( the sexual health charity) 2017
ii. Cooper, M, Cameron, S. Postpartum contraception. The Obstetrician & Gynaecologist. 2018; 20: 159– 166. https://doi.org/10.1111/tog.12494
iii. https://www.nhs.uk/conditions/contraception/when-contraception-after-baby/?tabname=methods-of-contraception
iv. FSRH Guideline Contraception after Pregnancy, January 2017